Programmatic adaptations to acute malnutrition screening and treatment during the COVID‐19 pandemic

Abstract The COVID‐19 pandemic presented numerous challenges to acute malnutrition screening and treatment. To enable continued case identification and service delivery while minimising transmission risks, many organisations and governments implemented adaptations to community‐based management of acute malnutrition (CMAM) programmes for children under 5. These included: Family mid‐upper arm circumference (MUAC); modified admission and discharge criteria; modified dosage of therapeutic foods; and reduced frequency of follow‐up visits. This paper presents qualitative findings from a larger mixed methods study to document practitioners' operational experiences and lessons learned from these adaptations. Findings reflect insights from 37 interviews representing 15 organisations in 17 countries, conducted between July 2020 and January 2021. Overall, interviewees indicated that adaptations were mostly well‐accepted by staff, caregivers and communities. Family MUAC filled screening gaps linked to COVID‐19 disruptions; however, challenges included long‐term accuracy of caregiver measurements; implementing an intervention that could increase demand for inconsistent services; and limited guidance to monitor programme quality and impact. Modified admission and discharge criteria and modified dosage streamlined logistics and implementation with positive impacts on staff workload and caregiver understanding of the programme. Reduced frequency of visits enabled social distancing by minimising crowding at facilities and lessened caregivers' need to travel. Concerns remained about how adaptations impacted children's identification for and progress through treatment and programme outcomes. Most respondents anticipated reverting to standard protocols once transmission risks were mitigated. Further evidence, including multi‐year programmatic data analysis and rigorous research, is needed in diverse contexts to understand adaptations' impacts, including how to ensure equity and mitigate unintended consequences.


| INTRODUCTION
Acute malnutrition remains a critical global challenge: an estimated 45.4 million children under 5 suffered from acute malnutrition in 2020 (United Nations Children's Fund World Health Organisation WHO & World Bank Group, 2021). Children with severe or moderate acute malnutrition (SAM or MAM) are at significantly increased risk of death and morbidity compared to nonmalnourished children (Black et al., 2008), with long-term impacts on physical and cognitive development. The COVID-19 pandemic is projected to exacerbate this challenge: estimates indicate that up to 9.3 million additional children may suffer from acute malnutrition due to economic impacts, increased food insecurity and interrupted health service provision (Headey et al., 2020;Osendarp et al., 2021).

| METHODS
This paper presents the qualitative findings from a larger mixed methods study conducted to identify, document and analyse protocol adaptations during the COVID-19 pandemic (Action Against Hunger USA, 2022). The target population for this study included global, national and subnational humanitarian aid practitioners from multilateral international organisations and nongovernmental organisations (NGOs). The research team was comprised of four Action Against Hunger staff, including one researcher with experience in CMAM implementation and qualitative analysis, one trained in qualitative analysis and two with extensive experience in acute malnutrition research.

| Sampling strategy and data collection
Interviewees were identified from respondents to a high-level survey, disseminated globally through practitioner networks, nutrition coordination mechanisms and NGOs, targeting stakeholders with
Further evidence is needed on long-term impacts.
• Family MUAC was well-accepted and addressed screening gaps from COVID-19 disruptions. Challenges included sustaining caregiver measurement accuracy; handling inaccurate self-referrals to encourage healthseeking behaviours; and limited programme design and monitoring guidance and tools.
• Modified admission criteria and therapeutic food dosage reduced contact between staff and children and streamlined logistics and implementation. Concerns remained about effects on programme admissions and outcomes.
• Reduced frequency of follow-up visits successfully reduced facility crowding and need for caregiver travel.
However, infrequent monitoring of childrenmay miss deterioration. specialised technical or operational knowledge of CMAM programmes and accompanying adaptations. The screening survey included simple questions about which adaptations were being implemented where and by whom; when adaptations started; and anticipated duration. Survey responses were collected from July 2020 to January 2021; summary statistics were published on a rolling basis on the State of Acute Malnutrition website to inform practitioners and policymakers of adaptation prevalence (No Wasted Lives, 2021). Respondents who consented to be contacted within the survey were invited to participate in interviews. Additional interview participants were identified through a combination of purposive sampling (based on geographic location or adaptations knowledge) and snowball sampling. Interviews were conducted between July 2020 and January 2021.

| Interviews
A semistructured interview guide was developed based on research questions identified as key evidence gaps through policymaker and practitioner consultations on CMAM programme adaptation implementation during the pandemic and simplified approaches more generally. These questions addressed the following themes: decision-making actors, processes and factors; staff and caregiver training; operational considerations (e.g., staffing, logistics, costs); and strengths, challenges and lessons learned, including perceived impacts on programme performance (e.g., admissions, programme outcomes). Each interview, conducted in English, verified survey responses and discussed the points above for each adaptation applied in the interviewee's area of work. Two research team members attended each interview, serving as an interviewer and a notetaker, respectively. The interview team discussed key findings and themes for further investigation after each interview and included these in summary memos.

| Data analysis
Recorded interviews were transcribed and qualitative data were analysed using thematic analysis, a flexible qualitative analysis method that identifies patterns across interviews corresponding to deductively and inductively identified themes (Braun & Clarke, 2008).
The four research team members developed a deductive codebook derived from the research questions and an initial literature review on simplified approaches, focusing on operational components of programme implementation (Action Against Hunger USA, 2021).
Inductive codes for new themes or notable subthemes were also added as necessary during analysis. Two team members with training and experience in qualitative research methods conducted data analysis using Dedoose qualitative analysis software, triangulating findings with interview summary memos. The first four transcripts were double coded by two reviewers independently to verify coder agreement. Subsequently, one out of five transcripts was randomly selected for double coding.
After coding all interviews, code reports were generated to show tagged quotations for each parent code in the codebook, organised by the corresponding adaptation. These quotes were reviewed and used to identify key findings, defined either as (1) observations identified consistently across multiple geographies; or (2) contextspecific factors that significantly impacted implementation. Coders developed iterative adaptation-specific analytical matrices, which identified takeaways for each theme, triangulated findings across interviews and contexts, and identified irregularities, contradictions and points for further investigation.

| Ethical approval and considerations
Ethical approval was obtained from Solutions IRB, a private accredited Institutional Review Board (Reference #2020/06/18). All participants provided written informed consent to participate and be recorded before any data collection. Participants were informed of the study objectives and intended usage of findings, as well as the principles of voluntary participation and right to withdraw. To ensure anonymity, each interview was assigned a unique reference number and identifiable information removed before analysis.

| RESULTS
In total, the research team conducted 43 interviews; six interviews were excluded from analysis: two due to a misalignment with study objectives, and four due to corrupted recording files. Findings therefore reflect analysis of 37 interviews representing 15 organisations in 17 countries across East Africa, West and Central Africa, Southeast Asia, South Asia and the Middle East (Table 1)  "We have a presentation which we made really simple for the village level health workers, so they can easily roll that out to the parents. And so we made the language pretty easy for them to understand … For the parents, we need to emphasize that they need to look at the color coding …. But it's important that we catch these children early and even before. If we can prevent, that's much better." (NGO Practitioner, Somalia) "There will be external people, but it will be easier for us to penetrate the communities using [local] volunteers because they know better the languages and the culture. They know how to explain things, which maybe we wouldn't be able to explain." (NGO Practitioner, Uganda) Caregiver training modalities differed across contexts, including delivery through existing group platforms (e.g., Care Groups) (Perry et al., 2015;SPRING Group, 2015) responsibilities. Another concern was the challenge in ensuring that CHWs received appropriate incentives or compensation for these additional responsibilities, a key barrier to scale up.

| Family MUAC
Family MUAC rollout also faced pandemic-related logistical challenges, particularly the inability to acquire sufficient MUAC tapes to meet increased training needs early in the pandemic. Extended procurement and shipment times due to lockdowns, travel restrictions and demand compounded these challenges. Furthermore, overlapping and occasionally unclear lines of procurement responsibility added to challenges.

| Strengths, challenges and opportunities
Some interviewees cited initial resistance to Family MUAC, including caregivers' lack of confidence to correctly measure their child, and community expectations that CHWs were solely responsible for taking these measurements. However, Family MUAC was quickly accepted by community members due to its simplicity. One interviewee noted that despite a long-standing wariness of all health interventions, communities saw Family MUAC's value and adopted it enthusiastically.
"Initially, most of the mothers would say, 'This is not our work. This is the work of frontline workers to Training: • Implementation of quality trainings and close collaboration with communities critical to build long-lasting support • Simple and engaging training materials targeted to low-literate audiences highly recommended • Common caregiver training modalities: care groups, one-on-one training at household level, small groups • Some higher training costs for Family MUAC compared to traditional CHW-led approaches with adherence to COVID-19 protocols to limit gathering sizes; virtual trainings reduced some costs Staffing and workload: • Shifted CHW responsibilities from screening to caregiver follow-up, refresher trainings and supervision, and measurement validation • Limited incentives available for CHWs to account for increased responsibilities Logistics and cost implications • Substantial delays in MUAC tape procurement due to supply chain issues and unclear lines of procurement responsibility • Limited funds initially available for rapid scaleup of trainings; later built into programme budgets Strengths: • Highly valued as an alternative or supplementary screening strategy • High community acceptance due to simplicity and perceived value • Strong programme staff acceptance due to the approach's focus on knowledge transfer, capacity building and increased community engagement Challenges: • Absence of guidance and materials on designing and implementing a Family MUAC programme early in the pandemic • Some caregiver reluctance due to low confidence about their own capacity and expectations for CHWs to take the measurements  Rasmussen et al., 2012).
However, some interviewees reported concerns that eliminating WHZ would exclude children with low WHZ who might benefit from treatment, since MUAC and WHZ do not always identify the same children (Grellety et al., 2015;Laillou et al., 2014). In Somalia, a significant drop in admissions motivated a reversion to standard admission criteria shortly after the adaptation was implemented.
To address the concerns of potentially excluding children who  Table 4 summarises key findings.

| Operational considerations
Respondents reported that modified dosage protocols were quicker and easier, successfully reducing children and caregivers' time at sites. For example, using a universal, standardised dosage (e.g., two sachets per child per day) enabled staff to prepare rations in advance. who implemented this adaptation during COVID-19 (see Table 5 for a summary of key findings). quickly depleted available supplies, as forecasts and procurement requests were previously based on weekly or biweekly calculations.

| Operational considerations
One interviewee initially reported needing increased staff for supply chain management, while another reported more streamlined stock management from procuring more supplies at once. Ultimately, the amount of product distributed remained the same but was distributed differently. Flexible supply chains and contingency plans were cited as key enabling factors to ease the transition to less frequent but larger distributions.
"Due to this change, our supplies were consumed quicker and even though we placed international order of more supplies well in advance … international suppliers took longer than usual and therefore our supplies went into a delay." (NGO Practitioner, Pakistan)

| Strengths, opportunities and challenges
Overall, this adaptation achieved its primary aim of reducing facility crowding, thereby minimising potential exposure to COVID-19. One interviewee in Malawi called this a 'blessing in disguise', observing that the approach could be particularly useful in contexts with a low prevalence of acute malnutrition and extended distances to facilities.
Interviewees also indicated that communities and caregivers accepted this adaptation well, as it alleviated the challenges associated with competing household responsibilities, transportation costs and traversing difficult terrain.
At each visit, caregivers are provided with a ration of therapeutic or supplementary food to last until the next visit. Reducing visit frequency therefore increased ration sizes, which caregivers reportedly struggled to manage in some contexts. This included storing and protecting the ration, particularly in a refugee camp setting with limited space, loss and theft, and properly dosing the product to last until the next visit. Proposed solutions included storing rations out of children's reach or providing locked boxes in which to keep the supplies, though neither assured complete security. However, several studies have also indicated that COVID-19 mitigation measures have unintentionally driven significant disruptions to health service provision and uptake (Inzaule et al., 2021;Kotlar et al., 2021;Walker et al., 2020). Within this study, interviewees expressed concern about potential impacts on CMAM programme admissions, children's progress throughout treatment, and programme outcomes; anecdotal validation of these concerns varied across contexts. Finally, the increased home visits and followup that some organisations implemented to mitigate negative impacts of the adaptations may pose additional transmission risks without sufficient PPE and IPC adherence. The lack of programmatic monitoring data compared to a control group highlights the need for more rigorous research and evidence on how these adaptations impact programme outcomes, as well as to document unintended consequences and both optimise protocols and build confidence among implementing staff.

| Lessons learned from adaptations
Implementation of Family MUAC during the pandemic demonstrated that it can complement existing screening activities, with the potential to expand screening coverage and fill gaps when routine screenings are insufficient or nonexistent. Furthermore, a benefit of self-screening approaches is earlier detection, which, when resulting in earlier enrolment in treatment, could result in improved programmatic outcomes (Austoker, 1994;Fleming et al., 2015;Roth et al., 2011). For example, a higher mean MUAC at admission is significant predictor of successful and sustained recovery (Stobaugh et al., 2019), and earlier detection may preclude more severe cases (ALIMA, 2016;Brown et al., 2019;Gnamien et al., 2021). Indeed, previous studies have shown that children referred through Family MUAC were less likely to require inpatient care (Alé et al., 2016).

However, increasing home-based screening through Family
MUAC is one small component of the causal chain between earlier identification and improved treatment outcomes. This study also identified the need for a functioning health system to maximise the benefits of self-assessment, both in terms of training on selfscreening and referral and service availability. Many caregivers face high opportunity costs to accessing care, a key barrier to healthseeking behaviours (Ahinkorah et al., 2021;Akinyemi et al., 2019;Blanárová et al., 2016). They may therefore be discouraged from seeking care again if they are turned away after an incorrect measurement or if the services they seek are unavailable. For example, interviewees expressed concern about long-term caregiver measurement accuracy, contrary to prior studies demonstrating caregiver capacity (Alé et al., 2016;Blackwell et al., 2015;Bliss et al., 2018;Grant et al., 2018). Inaccurate measurements could result from a knowledge decline after initial training, noted in multiple contexts (UNICEF, 2020 (Aguayo et al., 2015;Briend et al., 2012;Grellety & Golden, 2016Rasmussen et al., 2012).
Operationally, increasing MUAC thresholds anecdotally increased caseloads and stretched resources, aligning with previous research findings ( Guesdon et al., 2021). This illustrates the critical need to identify and optimise inclusion of prioritised groups while accounting for the realities of supply and budget constraints in the context of an abrupt change in targeting criteria, whether for CMAM or other programming.
In general, modifying the dosage of RUTF was a reactive adaptation to compensate for suspended weight measurements.
However, it was lauded for its impact on streamlining processes and reducing caregivers' time at facilities, in addition to improving caregivers' understanding of the overall programme. Other studies have suggested that the approach may enable treatment of more children given less food product used per child (Bailey et al., 2020;Daures et al., 2020;Maust et al., 2015;N'Diaye et al., 2021), as commented by one interviewee; however, these data were not collected during this study. While several interviewees expressed concern about potentially negative impacts on children's progress contact with the health system without compensatory measures could render them more vulnerable to deterioration, delay concurrent disease identification, and interrupt routine immunisations and supplementation (Inzaule et al., 2021). The evidence base on this adaptation specifically is limited to date (Hanson, 2019;Isanaka et al., 2017). Further programmatic data analysis is necessary to understand if, how, and through what causal link this adaptation could affect health service utilisation and programme outcomes, such as LOS.

| Strengths and limitations
A key strength of this study is the breadth of practitioners interviewed, providing insights into the application of these approaches in myriad contexts and offering general takeaways alongside context-specific findings. However, due to the qualitative and context-specific nature of these findings, results should be interpreted as indicative only of practitioner experience. Qualitative findings are restricted to those who responded to requests for interview, and therefore, qualitative data was not collected for all adaptations implemented globally. Finally, most interviews took place within a few months of adaptation rollout. Findings therefore strongly reflect experiences in the early stages of implementation and may be less applicable in later stages.

| CONCLUSION
The COVID-19 pandemic encouraged a paradigm shift in CMAM programming, as pandemic conditions challenged current service provision protocols. This raises the question of which CMAM programme components should be maintained, adapted and strengthened, both during the pandemic and beyond. The protocol adaptations analysed in this study addressed immediate needs for continuity of care while reducing some transmission risks and were mostly well-accepted by caregivers and staff. However, more rigorous evidence is needed on programme impacts and outcomes. Finally, the pandemic demonstrated once again that necessity spurs innovation: these approaches had been piloted previously but were implemented at a greater scale than ever before due to COVID-19 restrictions. During the pandemic, donors and governments created an enabling environment in which to challenge the status quo, with prospectively positive implications for programming beyond COVID-19.
Moving forward, such creative thinking should not be exclusively